Neurolytic Visceral Sympathetic Blocks

Neurolytic sympathetic blocks can be very helpful in controlling pain that is visceral in origin. Visceral pain can occur when visceral structures are involved with cancer due to pressure, invasion, or stretching. Visceral pain can be dull, squeezing, and poorly localized. Referred pain can occur due to visceral pain. For example, patient can experience pain in the shoulder when the diaphragm is involved in the tumor. Sympathetic block can help visceral pain only. This means that other forms of pain that may be associated with the tumor cannot be affected and does not mean that the block is not successful. Visceral pain is transmitted along the

Perineum, distal rectum and anus, distal urethra, vulva, and distal third of vagina

Figure 28.4 Schematic outline of the sympathetic nervous system with ganglia amenable to blockade highlighted.

sympathetic nervous system from the involved organ, relaying in para-vertebral ganglia that lie along the anterolateral portion of the vertebral column (Fig. 28.4). These ganglia are in perfect location for neurolytic destruction in case of cancer pain

Before performing any neurolytic block the physician should obtain pain history, and physical examination with identification of cancer as the main reason of pain. Neurological examination is mandatory before performing neurolytic blocks in order to identify any preexisting neurological deficit. The physician should perform examination of the site of the block to identify the presence of any infection and obtain coagulation profile including PT, INR, PTT, and platelet count because some of the cancer medications can affect platelets function and coagulation factors. The patient should have received appropriate trials of opioid and there should be a documentation of intolerance to opioids or ineffectiveness of opioids in relieving pain, despite increasing the dose. The physician should also obtain informed consent, explain in detail the procedure to the patient and also to the family if required, explain in detail and document all the risks and benefits of the blocks including the alternatives, the projected analgesic response, and the expected goals of therapy. Performance of local anesthetic block prior to neurolytic block is essential. This will enable the patient to be aware of the effect and possible side effects of the block, and also it will the patient and the healthcare providers to identify any neurologic deficits that may be intolerable to the patient. The most common neurolytic agents are alcohol or phenol. They both have equal effects. Table 28.6 shows the differences between alcohol and phenol as neurolytic agents.

Figure 28.4 Schematic outline of the sympathetic nervous system with ganglia amenable to blockade highlighted.

Table 28.6 Differences between alcohol and phenol as neurolytic agents.

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